Section 5

Oropharyngeal Airway

• The posterior tip of the airway should rest at the base of the tongue
• If the airway is too small, there is continued obstruction
• If the airway is too large, the epiglottis will be held shut

Nasopharyngeal Airway

• Separates the tongue from the soft palate
• Use the largest size possible
• The tip should rest between the tongue and the soft palate
• If the airway is too small, there is continued obstruction
• If the airway is too large, the epiglottis will be held shut

Laryngeal Mask Airway

• The tip is designed to rest against the upper esophageal sphincter
• Sides face the pyriform fossae, lying just under the base of the tongue
• Seals off the esophagus
• Ensure black line faces the upper lip
• Placement should be confirmed with breath sounds, end-tidal CO2, and chest x-ray

Manual Resuscitators

• Provide a means of delivering positive-pressure ventilation to a patient's airway
• Ventilate bradypneic or apneic patients
• Hyperinflate patients with oxygen before and after suctioning procedures
• Generate airway pressures and large tidal volumes to expand atelectatic lung segments
• Allow for the addition of positive end-expiratory pressure (PEEP) valves

Flow-Inflating Manual Resuscitators

• Rely on gas flow to inflate them
• Mostly disposable
• May deliver 100% oxygen or any FiO2 if set on a blender
• Little "built-in" resistance
• Allows you to "feel" the lung compliance
• Harder to bag indicates worsening lung compliance

Permanent, Self-Inflating Manual Resuscitators

• Designed to be cleaned and reused

Mouth-To-Mask Devices

• These are manually operated ventilators

Intubation Equipment

• **Laryngoscopes and Blades **
  • Miller laryngoscope blade - designed to directly lift the epiglottis
  • Macintosh laryngoscope blade - designed to slip into the vallecula (indirectly lift epiglottis)
• Equipment Used to Assist in Intubation
  • Magill forceps
  • Stylet
  • Yankauer suction (tonsil tip)
  • End tidal CO2 detection

Endotracheal Tubes

• Cuffed and uncuffed tubes
• Mallinckrodt Hi-Lo® Evac endotracheal tube - suction lumen just above the cuff
• Wire reinforced endotracheal tubes - used to prevent kinking
• Oral and Nasal RAE® tubes - have a bend to move the circuit from the airway
• Endobronchial endotracheal tubes
  • Carlens tube (2 cuffs, intubate L mainstem)
  • Robertshaw tube (2 cuffs, intubate R or L mainstem)

The Importance of Poiseuille’s Law

• Smaller airway = work of breathing
• As radius is reduced by half, resistance increases by 16 times
• This imposed work of breathing can be significant
• Small artificial airways can make weaning from mechanical ventilation more difficult
• Adults: Height dependent
  • Female: 6.5 - 7.5
  • Male: 7.0 - 8.0
• Formula for Pediatrics: (age in years+ 16)/4 = approximate size of ETT

Larger inner diameter = less resistance

• Smaller inner diameter = more resistance

Forces Exerted by Artificial Airway Cuffs

• P=F/A
• High-volume, low-pressure cuffs
  • Endotracheal tube
  • Trachs
  • Volume = more surface area = less P to seal the tube against the tracheal wall
  • Less pressure on tracheal mucosa
  • Age cutoff for cuffs is 8 years (not absolute)

Cuff Pressure Measurement Techniques

• Minimal occlusion volume
• Minimal leak
• Cuff Pressure Manometers
  • Mechanical manometer & 3-way stopcock
  • Posey cufflator
  • DHD Cuff-Mate2
• Measured/filled via pilot balloon

MLV vs MOV

• Minimal Leak Volume
  • Auscultate upper airway
  • Add air to cuff until leak disappears
  • Remove a small amount until leak is just heard again
• Minimal Occlusive Volume
  • Auscultate upper airway
  • Add air to cuff until leak just disappears
• Also called minimal leak/occlusive technique (MLT/MOT)

Cuff Pressure Manometers

• Measure the pressure in the cuff used to seal the trachea
• 20-30 cm H2O
• Calibrated to atmospheric pressure

Cuff Pressure Measurement Continued

• Respironics PressureEasy
  • Helps with tubes having a "leaky" cuff
  • Adds pressure to cuff during inspiration, when it is needed most
  • Utilizes positive pressure from ventilator
  • Cuff pressure is reduced during exhalation

Murphy Eye

• This is a small hole on the endotracheal tube that helps reduce pressure on the tracheal wall

Hi-Lo Evac Endotracheal Tube

• This tube has a suction lumen just above the cuff which helps to remove secretions

Wire-Wrapped Reinforced ETT

• This type of tube is used to prevent kinking

Right Angle Endotracheal Tube (RAE)

• This tube has a bend that moves the circuit from the airway - It is often used for nasal intubation

Carlens Endobronchial ETT for independent lung ventilation

• This tube has two cuffs that allow the left mainstem to be intubated

Robertshaw Endobronchial ETT

• This tube has two cuffs that allow either the left or right mainstem to be intubated

Combitube Airway

• Double lumen
  • Esophageal gastric airway
  • Endotracheal tube
• Designed for blind insertion
• 2 cuffs (inflate both)
• Ventilate through either port, confirming which produces chest rise and adequate ventilation

Combitube Insertion Video

• There is a link to a Combitube insertion video. Please see the text for the link

Intubation Equipment Continued

• Endotracheal Tube Exchanger
  • Facilitates removal and replacement of an endotracheal tube
  • Tube change is sometimes necessary due to:
    • Blown cuff
    • Upsizing
    • Damaged
  • Threaded through old tube, remains in place when the tube is removed, new tube is fed over it.
  • Guaranteed to go through vocal cords if the old tube was properly in place

Tube Exchanger

• This device is used to help with the removal and replacement of an endotracheal tube

Tracheostomy Tubes

• Bypass the entire upper airway
• Incision is usually made between the second and third tracheal rings

Tracheostomy Tubes Continued

• Cuffed, Disposable Tracheostomy Tube
• Cuffed Tracheostomy Tube with a Disposable Inner Cannula
• Fenestrated Tracheostomy Tube
• Silver Jackson Tracheostomy Tube
• Communi-Trach
• There is a link to a tracheostomy video. Please see the text for the link

Cuffed, Disposable Tracheostomy Tube

• Contains cuff and pilot balloon
• No disposable inner cannula; entire trach is changed periodically
• Usually made of PVC

Cuffed Tracheostomy Tube with a Disposable Inner Cannula

• Most common now
• Inner cannula is removable
• No need to change the entire trach unless the patency of the cuff is in question
• Many hospitals will change weekly

Fenestrated Tracheostomy Tube

• Contains a removable inner cannula
• When the inner cannula is removed and the balloon is deflated, the patient may breathe through the upper airway
• Often used for weaning purposes
• With the cuff inflated and the inner cannula inserted, mechanical ventilation is possible

Silver Jackson Tracheostomy Tube

• May be used as a permanent trach
• Cuffless and made from sterling silver
• Silver is more durable and easier to clean
• Not very common these days

Communi-Trach

• a.k.a. Pitt Speaking Tube
• Facilitates speech with an inflated cuff
• Blows oxygen by vocal chords via fenestration
• Patient may speak without using their own expiratory gas flow
• Often difficult for the patient to coordinate
• Speech is not "normal" sounding

Specialized Weaning Devices

• Maintain patency of stoma during weaning
  • Olympic Trach-TalkTM
  • Passy-Muir Tracheostomy Valve
  • Trach Button
  • Kistner Button

Olympic Trach-TalkTM

• A Briggs adapter with a spring-loaded valve
• Allows the patient to inspire through the trach, but must expire through the upper airway
• Trach cuff must be deflated! Otherwise, the patient could not exhale!

Passy-Muir Tracheostomy Valve

• Small one-way valve that facilitates speech
• Cuff must be deflated or patient cannot exhale!
• Very common, some consider it the gold standard of speaking valves

Passy-Muir Valve

• There is a link to a Passy-Muir Valve video. Please see the text for the link

Trach Button

• Used to maintain the stoma after the tracheostomy has been removed
• Consists of: inner cannula, plug, IPPB adapter, spacers
  • Plug closes the stoma so the patient can breathe through the upper airway
  • IPPB adapter allows mechanical ventilation (no cuff)
  • Spacers adapt to varying neck thickness

Kistner Button

• Trach button with a one-way valve
• Cannot be used with mechanical ventilation
• One-way valve forces the patient to exhale through the upper airway
  • Facilitates speech
  • Allows for a more effective cough

Secretion Evacuation Devices

• Suction Regulators
• Suction Catheters
• AARC Clinical Practice Guideline: Endotracheal Suctioning of Mechanically Ventilated Adults and Children with Artificial Airways

Suction Regulators

• Use a single-stage regulator to reduce the high negative pressures from the supply line to safe physiological levels
• Generally, we don’t need to go > 120mmHg
• Must occlude to accurately read pressure!

Test your knowledge on oropharyngeal, nasopharyngeal, and laryngeal mask airways, as well as manual resuscitators. This quiz covers specifications and placement techniques essential for effective airway management. Evaluate your understanding of these crucial concepts in emergency medicine.